Tag Archives: Podiatry

With Diabetes Assuming Epidemic Proportions, Foot Doctors Look For A Leg Up

PODIATRISTS, tenders of corns, bunions and other troubles of the humble foot, are classified as second-class citizens in the medical world – a rung below full-fledged M.D.s. But with the surge in people with diabetes, they’re playing a particularly vital role these days in preventing amputations. And there’s a move afoot to boost their official status as well, reports Jan Ferris of the Sacramento Bee.

Dr Jon A. Hultman

“We kind of see ourselves as the profession that keeps people walking,” said Dr. Jon Hultman, executive director of the California Podiatric Medical Association.

Obesity is the primary culprit for the boom in cases of type 2, or adult-onset, diabetes. As the numbers rise, so does the need for early treatment – especially of foot sores or ulcers that can quickly threaten the lower limbs. Sixty percent of all non-traumatic amputations in the U.S. are due to diabetes, according to the American Diabetes Association.

Indeed, podiatry (foot care) for people with diabetes is one of the most overlooked aspects of diabetes management. Reviewing the community discussion regarding podiatry and particularly for visiting podiatrists reveals that many people with diabetes are entirely unaware that they need to take special care of their feet and visit a podiatrist at once if problems arise. Higher levels of blood glucose can damage the nerve endings in many areas of the body and organs, which is why tight blood glucose control is an essential aspect of diabetes care.

But here’s the thing: Though podiatrists can operate on the foot and ankle, give injections and provide other medical care, they aren’t licensed doctors of medicine, or M.D.s. As such, Hultman and others maintain, the state’s 1,800 doctors of podiatric medicine (DPMs) are hamstrung by law from treating many of the 7.5 million Californians insured through Medi-Cal (due to a 2009 state budget cut), partnering fully in the hospital care of diabetic patients and gaining access to first-rate residencies in their podiatric training.

“We’ve evolved over the last 30 or 40 years. What hasn’t changed is this limited license,” Hultman said. “We’re treated differently even though the way we practice is essentially the same.”

Indeed, on a given day with the Sutter Medical Group, 30-year podiatrist Dr. Spencer Lockson treats the foot from several angles: dermatological, as in athlete’s foot and eczema; bone and joint issues, such as bunions, fractures and “hammer toe” deformities; and nerve conditions, which are often associated with diabetes. “We avoid amputations the best we can,” he said.

Foot Doctors Can Help Diabetics Avoid Amputation

Podiatrists have attracted an unlikely ally in the bid to boost their status: the California Medical Association. The powerful doctors’ lobbying group is notorious for its turf battles with chiropractors, nurse practitioners and others it defines as “mid-level practitioners and other allied health professionals.”

But this time around, the CMA is playing the opposite role. It’s teaming up with the California Podiatric Medical Association and the California Orthopaedic Association to consider putting the training of foot specialists on par with M.D. standards, according to CMA Chief Executive Officer Dustin Corcoran.

The three groups are creating a task force to review the curriculum at California’s two podiatry schools and, depending on the outcome, appeal jointly to the national Liaison Committee on Medical Education to reclassify the licensing for podiatrists.

Dr. Lawrence Harkless, a podiatrist and dean of the Pomona-based College of Podiatric Medicine at the Western University of Health Sciences, believes the move makes good sense. “I don’t have an M.D., but I practice medicine every day. If I’m that close, why not just be it?” he said.

The first two years of podiatric training are similar to those for full-fledged physicians, with the emphasis on anatomy, physiology, pathology and other core subjects. Podiatry students jump into more specialized training the next two years, then generally spend the last two or three years as hospital residents. Training for licensed medical doctors generally takes several years longer, with the length for residencies determined by the specialty.

At his first hospital internship in Texas in the 1970s, Harkless worried he’d be less prepared than his M.D. peers. “After two months, I knew I learned more than anybody about feet,” said Harkless, considered a national pioneer in the field of diabetic limb salvage. “But if you have a different degree, they want to make you feel less than.”

Corcoran of the California Medical Association agrees the perception is not always favorable. He and Hultman are expecting pushback on the collaboration to bring podiatry into the medical mainstream. “There will be a freak-out, those naysayers, who say, ‘They’re just the foot guys and will always just be the foot guys’,” said Corcoran. But this is really how scope of practice should be decided.”

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With a physician shortage in California, and the aging baby boomers’ growing need for care, podiatry may become a more attractive option if granted M.D. status, he added.

Franklin High School graduate Brittany Rice just completed her first year at the California Podiatric School of Medicine at Samuel Merritt University in Oakland. She is used to frequently explaining that podiatry is a credible medical field. “I know people in society put the M.D. on a higher pedestal. They don’t take us seriously,” said Rice, who is considering specializing in diabetes care. “Not that (a change in licensing) would affect what I do, just how people perceive the profession.”

Sacramento podiatrist Kevin Kirby isn’t convinced. He chose podiatry school in the 1980s, in part because of its “efficient” focus on the foot and a postgraduate commitment of six years instead of eight or nine. If new requirements called for additional training, he wonders if students would just choose a different branch of medicine.

“I never had the feeling that I was a lesser doctor because I had a DPM,” said Kirby, who is on staff at two Sacramento hospitals and shares his practice with an orthopedic surgeon. “For me, I don’t lose any sleep over this. I’m plenty busy. I do a lot of good for people.”

Courtesy: Sacramento Bee

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Diabetes: Understanding Charcot Foot

For diabetics, foot care is one of the most important aspects of managing the disease. Four out of ten people with diabetes are thought to have lost some feeling in their feet, and nearly half will suffer a foot wound or ulceration in their lifetime. But there are some conditions that are out of the ordinary and one of them is the Charcot foot.

The Charcot foot is a rare condition that can occur in some people with diabetes. The underlying factor that contributes to the development of this condition is a loss of sensation in your feet—nerve damage that is referred to as peripheral sensory neuropathy.

Neuropathy is a common complication of diabetes, seen in people with both type 1 and type 2. The earliest sign of the Charcot foot may be a sudden and unexpected change in the appearance of your foot or ankle, characterized by redness, swelling, and warmth. You may have no recollection of injury.

X-rays of the foot may initially look perfectly normal, or there may be very subtle changes that can be easily missed. This is the most important stage of the Charcot foot for the physician to recognize the problem and to start treatment immediately. The treatment involves rest, elevation of your foot, and, most important, staying off of the affected foot until inflammation subsides and the foot is stable.

Sometimes there is collapse of the arch with the development of bony deformity, a “rocker-bottom foot,” with formation of an open sore (ulcer) on the bottom of the foot. Your doctor will first need to confirm the diagnosis by eliminating other conditions that might have a similar appearance, such as infection or gout.

Most diabetic foot specialists will apply a short non-weight-bearing cast and monitor the condition closely. Serial X-rays are taken to evaluate the healing of fractures and dislocations of one or more joints.

Although we have not yet learned how to prevent the development of a Charcot foot, we can sometimes minimize the extent of deformity with early recognition and prompt treatment. The likelihood of success decreases as the patient passes through the chronic stage of this condition.

Immobilization in a cast can sometimes take three months or longer. Patients are often transitioned from a cast to a removable walking brace, and then to a special shoe. In most cases, patients can be treated with non-surgical care; in the most difficult cases, surgery may be necessary.

Treatment of the Charcot foot is often prolonged, challenging, and frustrating. If you are at high risk—if you have peripheral neuropathy and loss of protective sensation—you should learn the implications of sensory loss, as well as the importance of diabetes self-management.

Foot inspection should be an important part of your daily routine. Compare one foot to the other and look for changes in size or shape. Is one foot swollen? Are there changes in the color or temperature of the skin? If you notice any of these changes, call your podiatrist, diabetes specialist, or family physician, and request an appointment as soon as possible.

Source: American Diabetes Associaltion

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